Background: Worldwide, multiple studies demonstrate a negative attitude of interns toward psychiatry. Scenario in Gujarat state has never been looked upon. The objective of this study is to identify the situation in this region by studying the attitude of interns toward various areas of psychiatry and to study the gender differences if any. Materials and Methods: For study, all 122 interns who attended psychiatry posting for the 1st time in their internship, over a period of 8 months were approached amongst which 100 (56 males and 44 females) consented to be a part. Attitude was measured with 30 items attitude toward psychiatry (ATP 30) questionnaire on the 1st day of their posting. The data thus collected were analyzed by SPSS version 20. Result: The results showed a neutral to the negative attitude in major areas of psychiatry. Most neutral responses were seen regarding contribution of psychiatric hospitals in the treatment, regarding psychiatric patients considered to be interesting and psychiatry enabling people to have rewarding relationships. Negative attitude toward areas on scientific information in psychiatry and psychotherapy's validity were obtained. While attitude was positive in areas of psychiatric knowledge and teaching, but female interns were lagging behind their male counterparts. Psychiatric treatment lessens worries and psychiatric illness should be considered at par with other medical illnesses, were most common positively viewed attitude. Conclusion: Interns overall shared a neutral to negative ATP. Adequate rectification is required in existing medical curriculum, and more exposure to the subject is essential to improve the attitude of interns toward mental health

According to WHO, health is defined as a "state of complete physical, mental and social wellbeing and not merely an absence of disease or infirmity" and currently the definition also includes the ability to lead a "socially and economically productive life." [1] But out of these, mental health has always been subject to negligence and undue suppression. Worldwide it is an on-going concern that psychiatry, psychiatrists, psychiatric illness and psychiatric patients are affected by negative prejudice [2] in spite of the following facts:

Point prevalence of mental illness in the adult population at any given time approximates 10% [3]

Mental illnesses will be the leading cause of years lost to disability by 2020 (surpassing AIDS and heart attack) [4]

Psychiatric disorders are amongst the top 10 causes of the economic burden while depression alone being second (WHO report) [5]

Around 20% of all patients seen by primary health care providers have one or more mental health problems. [6]

Prevailing stigma toward mental illness in society at large and also in other health care professionals [19]

Less scientific, more religious, magical and supernatural etiological and treatment approaches for mental illness, particularly significant in rural areas [20]

Current Medical Council of India guidelines does not give any standardized weightage to psychiatry as far as MBBS exams are considered, which is far below as compared to scenario in other countries like America and Britain [6] where 60-80 h of teaching followed by around a month of clerkship is mandatory. Hence, an Indian undergraduate doctor has only a meager exposure that to very little to clinical psychiatry. That will be the only psychiatry learned (apart from 15 days internship clinical posting) if the individual chooses other specialty apart from psychiatry.

Many previous studies have been done regarding attitude of interns toward psychiatry highlighting the importance of studying this area in detail across different regions of India. The results of those studies have been dismally low, majority of them pointing toward a preconceived negative ATP. [2],[21],[22],[23] One of the numerous causes to this dismally low outcomes can be the half-hearted way in which psychiatry subject is introduced in the undergraduate curriculum.

In India, many steps are being taken to reduce the knowledge, attitude, practice (KAP) gap in medical fraternity as per the guidelines chalked out under National Mental Health Program launched by Government of India in 1982, one of the suggested way is by educating them. Several studies have shown a positive outcome by this approach. [13],[14] More robust way however will be to bring about the change right from the beginning. This beginning in professional medical field is the period of internship. Relevant clinical knowledge of psychiatry, if imparted to students, can help them in other medical branches also as well as the stigma toward psychiatry will be taken care of.

It is of great importance to know the attitude of interns toward psychiatry as these interns are currently involved indirectly or in the future, directly toward the delivery of healthcare. If they have negative attitude, or any misconception then it is detrimental not only to the psychiatric patients, but to society at large because a common person will always follow and get influenced by what these young doctors have to say. In the current scenario, a vast majority of psychiatric patients are not receiving optimal and expert care either due to lesser availability of trained professionals.

As of now, there are no such studies done in the western part of India specifically in Gujarat (Ahmedabad city), also the gender difference in the ATP has never been the subject of any Indian study. The female representation in the psychiatry fraternity is meager as compared to other specialties. Existing referral system to psychiatry sub specialty by general practitioners is infrequent (another indicator of the existing KAP gap). Gujarat is having 0.4 psychiatrists and 0.002 psychologists per lakh population. Monitory wise also, Gujarat is spending only 3% of its budget on mental health, [24] this makes the attempt to study the attitude of interns and improve if found deficient, an utmost necessity as this problem can be only countered by having a strong motivated and positive outlook toward mental illnesses that in-turn is possible only if the concerned person has a positive attitude. With this much to look at, we conducted this study to:

Understand the attitude of interns toward psychiatry at large

Understand and identify the attitude in major areas of psychiatry that is

Psychiatric patients and illness

Psychiatry and psychiatrists

Psychiatric treatment and hospitals

Psychiatric knowledge and teaching

Study gender differences, if any.

Materials and Methods

The study was conducted at a tertiary care teaching medical college of Ahmedabad. A total of 122 interns posted at the Psychiatry Department of our hospital, who had no prior exposure to psychiatry in their internship, were approached over a period of about 8 months, on the 1 st day of their posting for being a part of the study. Out of the total students approached, 100 (56 males and 44 females) consented to take part (response rate of 81.9%). Emphasizing confidentiality, the consenting interns were requested to fill ATP 30 questionnaire along with basic sociodemographic variables and name at their own discretion. The ATP 30 scale was designed and validated by Burra etal. by their study on Canadian students. [25] Since its formulation, the scale has been used in multiple surveys across different nations in the original English form and has proven its validity. It has adequate face validity, construct validity, split half reliability and high test-retest reliability. Also, successful usage of this tool in two of the previous Indian studies by Tharyan et al.[26] and Konwar et al.[27] prompted us to use this tool in our study.

Considering our subjects, having completed their MBBS and have good English proficiency, the scale was used in its original form. ATP 30 is a five-point Likert type scale that records responses of individuals (strong agreement, agreement, neutral, disagreement, strong disagreement). It comprises of 30 questions with 15 indicating positive attitude, which are scored from 5 to 1 and 15 indicative of negative attitude, scored reversely, higher score indicative of more positive attitude.

The instrument showed good internal consistency in this study (Cronbach's alpha = 0.874). For detailed study of the core areas of psychiatry, the components of the scale were clubbed under different subgroups namely-ATP patients and illness, psychiatrists and psychiatry, psychiatric treatment and hospitals, psychiatric knowledge and teaching, as done in a previous study. [28] The data thus obtained were analyzed by IBM SPSS Statistics Data Editor version. 20. Descriptive statistics were used to describe the data that is, frequencies and percentages for categorical variables; means and standard deviations (SDs) for continuous variables. Independent samples t-test was used to find the gender difference in ATP on the whole, as well as the various subgroups of ATP 30 as described above. χ2 was used to analyze gender differences in response to individual statements. Significance was set at P < 0.05.

Results

The final sample included a total of 100 interns with 44 females (44%) and 56 males (56%).

[Table 1] shows scores obtained from the total sample, categorized according to subgroups and gender, clearly showing a significant lacunae in scores of females toward psychiatric knowledge and teaching as compared to males. On the whole also males had a more positive attitude as compared to female interns.

Table 1: Scores on ATP 30, its subgroups and its association with gender

[Table 2] shows responses to statements depicting ATP patients, psychiatric illness; psychiatrists and psychiatry suggestive of a more neutral to the negative attitude. [Table 3] comprises of responses to statements suggestive of ATP treatment, hospitals; psychiatric knowledge and teaching once again pointing to a fact that interns are having a more unconcerned response toward these, but a slightly more positive response toward knowledge and teaching in psychiatry. [Table 4] shows the three statements having a significant gender difference in their responses from the 30 statements of the ATP 30 questionnaire on which χ2 test with P < 0.05 was applied for significance.

This is first of its kind study conducted in Gujarat state. The growing concerns regarding mental illnesses and the apprehended lack of awareness about the same in young doctors was the driving force behind this study. The Indian medical education system comprises of 4.5 years of teaching time with 1-year of internship, during which there are mandatory postings to various clinical departments. Regarding psychiatry, at large, this is being looked upon casually. Lack of proper exposure and training in psychiatry may be postulated as a probable reason for poor awareness and prevalent negative attitude amongst Indian students, as also evidenced by studies done by Chawla etal. [22] and Yadav etal. [24] and in Pakistan done by Niaz etal. [23] This accounts for the sample selected for our study as interns who had no prior psychiatric internship posting. The statements of the questionnaire used made it possible to study the attitude in various dimensions like toward psychiatric patients, psychiatric illness, psychiatrists, psychiatry, psychiatric treatment, psychiatric hospitals, psychiatry knowledge and teaching.

[Table 1] depicts mean, SD and range of scores obtained in our sample with distinction into subgroups and gender along with their significance. According to our study, females are having little less positive attitude than males. Also in the previous study done by Konwar et al.[27] from India, undergraduate medical students were found to have multiple lacunae in their knowledge toward psychiatry, psychiatric disorders, psychiatric patients and psychiatric treatment which however was found to be less in the students who had underwent 2 weeks clinical training. In study by Khan et al.[28] at Pakistan in 2008, females showed a more positive attitude, while in our study they are lagging behind males, maybe because they had included undergraduate students in their study while we have included only interns in our study.

[Table 2], part 1 shows ATP patients and psychiatric illness in which 3 out of 4 items showed more neutral to negative attitude (76% feel that psychiatric patients are interesting to work with, 74% feeling that psychiatric patients are just human and another 73% believing that cause of psychiatric illness is interesting to find out) and only one (need for attention toward psychiatric illness as compared to medical illness) is having more positive response (50%). A study in India by Tharyan et al. [26] in 2001 also had similar findings. Part 2 shows attitude toward psychiatrists and psychiatry and has 11 items most of them (eight) showed neutral to negative response (76% shows neutral to negative attitude regarding rewarding relationship with people due to practice of psychiatry and 74% reported neutral to negative attitude regarding stability of psychiatrist as an average doctor) about one-third are not happy to become a psychiatrist and about 29% believed that psychiatrist will not get satisfaction from their work as shown in [Figure 1]. Such findings were also obtained in other studies by Malhi et al. [16] and Minhas and Mubbasher. [17] It indicates that the interns are not considering a psychiatrist as a stable person and think of them as unable of having a stable relationship, pointing toward common people referring to psychiatrists as not much different from their patients. Only three items show a more positive attitude: 46% stated that they consider psychiatrists as equal to other doctors, 45% considered psychiatry to be amongst top three exciting specialties, and 44% felt that it is an appealing branch, as shown in [Figure 2], while this group indicates toward interns, really adequately exposed to psychiatry of having a more positive attitude others point to a group that needs to be worked upon to escalate their attitude.

Figure 1: Statements having most negative responses*. *indicating more negative attitude; in question numbers - 2, 4; negative response indicates agreement and in question number - 1, 3; negative indicates disagreement to the statement of the question. Y axis = number of responses

[Table 3], part 1 shows ATP treatment and hospitals. About 62% could not decide on the role of psychiatric hospitals in treating mentally ill. One-third felt that psychotherapy is fraudulent and doubted the efficacy of psychiatric treatment. About half of the interns believed that psychiatric treatment causes patient to lessen their worry about their symptoms. Studies in European countries [7],[8],[9],[10] and India [12],[13],[14],[15] also show a similar picture. From the results, lack of belief in efficacy of psychiatric treatment was clearly evident in almost a third of sample, which can be worked upon by educating the young doctors as education definitely improves awareness; evident in studies by Corrigan etal. [29],[30] Part 2 shows ATP knowledge and teaching; one-third believed that psychiatry has very little scientific information to propagate and more than half were uncertain about the importance of psychiatry in undergraduate curriculum but 42% of the interns found their undergraduate psychiatric training to be of value. An overall outlook clearly points toward a more neutral attitude in current internship students probably due to lack of a clear picture regarding psychiatry as a branch [31] or due to prevailing stigma, [31],[32] which is also the scenario in our neighboring country Pakistan (Minhas and Mubbasher [17] ), which can definitely be worked upon to improve the scenario.

[Table 4] depicts statements having a significant gender differences in their responses, with more females considering psychiatry as not equally respectful to other medical specialties and also psychiatrists getting less satisfaction from their work. Half of the females dismissed the idea of psychiatry being unscientific. Some of the studies in European countries by Alexander and Eagles [32] and Wilkinson et al. [33] have pointed toward the same difference.

Many studies have been carried out in the world addressing the attitude of medical students toward psychiatry. However, the results of these studies are not encouraging. Therefore, it is suggested that a study with larger sample having homogenous properties of subjects from different medical colleges of this area may be carried out or similar study may be conducted in the rest of the colleges of this geographic region to conclude more holistically. Moreover, more elaborate and open-ended questionnaire may be incorporated to find out and make apt measures for the divide between the ideal and the ground realities in the field of mental health.

Conclusion

Interns overall shared a more neutral to negative ATP. The internship students had many gaps in their knowledge toward psychiatry, psychiatric disorders, psychiatric patients, psychiatric treatment and psychiatrists. The possible reasons could be many. But a potential easily rectifiable fact could be the casual approach with which, we address Psychiatry at undergraduate level, superimposed on the already existing stigma. The lesser number of hours assigned to psychiatry and absence of mandatory separate section in theory exams add to the cause by creating a neglect in mind of students. Subjects such as psychiatry are underrepresented also during the practical training. This negative attitude can be amenable to change on the positive side by correctly modifying the undergraduate medical curriculum by giving more weightage toward psychiatry both in forms of marks allotted in exams and also hours allotted in training. This is of prime importance in current times of stress era when the psychiatric illnesses are rampant and so much importance is given to mental health, both at national and international level.